The Curbsiders Internal Medicine Podcast · The Curbsiders Internal Medicine Podcast

#499 Inpatient DOAC Dilemmas with Dr. Jori May

·1 hr 7 min·4 clips

"It's extremely rare for anticoagulation to fail" becomes the episode's central challenge to the usual reflex.

1. The Curbsiders Internal Medicine Podcast #499 focuses on inpatient DOAC dilemmas for the hospitalist. 2. Hosts Moni Amin and Meredith Trubitt speak with Dr. Jory May, a UAB hematology-oncology physician advisor for hemostatic and antithrombotic stewardship. 3. The episode asks how to decide whether a suspected clot on apixaban or rivaroxaban is true anticoagulation failure. 4. Dr. May says anticoagulation failure is "extremely rare" and starts with fill history, adherence, and dose verification. 5. She gives the specific example that full-dose rivaroxaban needs food and apixaban should be taken twice daily. 6. She notes that atrial fibrillation dose-reduction criteria can leave a VTE patient underdosed on apixaban. 7. She distinguishes new thrombus from old clot by asking for prior imaging, comparing the location, and sometimes checking D-dimer. 8. She explains that anti-10A testing only helps if the assay is calibrated for direct oral anticoagulants rather than heparin products. 9. She reviews absorption issues, including apixaban's colonic absorption and rivaroxaban's need for food. 10. She also flags altered gastric anatomy and bowel surgery as reasons to question oral absorption. 11. For obesity, she cites the International Society of Thrombosis and Hemostasis' more recent comfort with BMI 30-plus and 40-ish patients. 12. She says she still hesitates at BMI 50 to 60 and may use warfarin early after a new VTE in that setting. 13. She mentions RENOVE clinical trial data supporting reduced-dose apixaban 2.5 mg twice daily for long-term secondary prevention. 14. For renal dysfunction, she says she generally favors apixaban over warfarin because of its lower dependence on renal clearance. 15. She says she will use apixaban in end-stage renal disease on dialysis while watching bleeding risk closely. 16. She discusses anatomical causes such as May-Thurner syndrome, thoracic outlet syndrome, and post-thrombotic scarring that can perpetuate thrombosis. 17. The tone is practical and consult-heavy, with repeated back-and-forth on real hospital cases and dosing edge cases. 18. The style is an expert interview that pauses often for clarification, including pharmacy history, radiology review, and risk-benefit reasoning. 19. Listeners who manage VTE, anticoagulation, or hospital consults will get the most value from this episode. 20. Listeners looking for broad introductory medicine content may not need this much detail.

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